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A new study investigating repeated violence in communities who are recovering from mass conflict suggests that this violence greatly increases community-wide post-traumatic stress disorder and severe distress.

In the aftermath of war, it is common for countries to be at increased risk of internal conflict. This persistent violence is known to hold back social, economic and political recovery. But until now, no studies have looked at the influence of repeating communal violence on the mental health of citizens.

Levels of post-traumatic stress disorder (PTSD) typically remain high in the 3 years after the end of war, with mental health gradually improving in following years.

The researchers behind the new study, from the University of New South Wales in Sydney, Australia, wondered if the continuation of violence in communities might cause sustained mental distress as it leaves citizens feeling a sense of persistent injustice.

The study, published in The Lancet Global Health, investigates how recurring conflict has affected the mental health of people in Timor-Leste.

An Indonesian occupation of this country between 1975 and 1999 led to a humanitarian crisis in the late nineties, which saw a period of extreme human rights violations, including torture, murder and mass displacement.

Although the University of New South Wales researchers found low levels of PTSD in a rural region of Timor-Leste that they studied in 2004, another period of intense violence erupted in 2006-2007, which undermined the previous sense of optimism the community had experienced upon achieving independence.

"Given that potentially traumatic events were rarer during the internal conflict than during the principal conflict, it seems likely that the effects of recurrent episodes of communal violence on the morale, sense of communal cohesion, and security of the population created a general underlying vulnerability to psychological distress", explains lead author Dr. Derrick Silove.

Seven-fold increase of PTSD in conflict-prone Timor-Leste, over 6 years of follow-up

"Persisting preoccupations with injustice" throughout both the original occupation and subsequent periods of violence was linked to a quadrupling of PTSD risk among Timor-Leste citizens.

Returning to Timor-Leste in 2010-2011, Dr. Silove and colleagues used the Harvard Trauma Questionnaire and the Kessler-10 questionnaire to measure PTSD, depression and anxiety in 600 adults from a rural village and 422 from an urban district.

They found that, over the 6 years of follow-up, there had been a seven-fold increase in rates of PTSD (from 2.3% in 2004 to 16.7% in 2010), and tripled rates of severe distress (from 5.6% to 15.9%).

The study found that the escalation in PTSD was not linked only to the communities' experience of conflict, however. The researchers identify that "persisting preoccupations with injustice" throughout both the original occupation and subsequent periods of violence was linked to a quadrupling of PTSD risk among citizens.

Dr. Silove considers that ongoing human rights abuses in combination with an "unsatisfactory truth and reconciliation process" following independence contributed to the rise in PTSD and severe distress.

"Our findings suggest that a period of internal conflict can result in a major escalation in mental disorders in post-conflict countries," he says, adding that:

"Mental health services should be enhanced in these settings to meet these increased needs. Our experiences highlight the importance of preventing communal violence, alleviating poverty, and addressing past and ongoing injustices in post-conflict communities to help avert both recurring violence and prevent an increase in mental disorders."

In 2011, Medical News Today reported on a similar study - published in JAMA - which found that war-displaced Sri Lankans were at higher risk of PTSD, anxiety and depression.

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